AMDA – The Society for Post-Acute and Long-Term Care Medicine

View all recommendations from this society

November 20, 2020

Don’t routinely prescribe or continue acetyl cholinesterase inhibitors or N-Methyl-D-Aspartate antagonists in patients with advanced dementia.

Use of acetyl cholinesterase inhibitors in mild to moderate dementia or NMDA antagonists in moderate to severe dementia may help with Behavioral and Psychological Symptoms of Dementia (BPSD) but have not been shown to prolong life. Once an individual is institutionalized, review of the risks and benefits of the medications should be reviewed periodically and de-prescribed when no longer demonstrating benefit to the patient. Acetyl cholinesterase inhibitors can worsen anorexia and NMDA receptor agonists are not indicated with severe renal insufficiency, both of which could be present in the older population.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

1–5: AMDA – The Society for Post -Acute and Long-Term Care Medicine convened a work group made up of members from the Clinical Practice Steering Committee (CPSC). Members of the CPSC include board certified geriatricians, certified medical directors, multi-facility medical directors, attending practitioners, physicians practicing in both office-based and nursing facility practice, physicians in rural, suburban and academic settings, those with university appointments, and more. It was important to AMDA that the workgroup chosen represent the core base of the AMDA membership. Ideas for the “five things” were solicited from the workgroup. Suggested elements were considered for appropriateness, relevance to the core of the specialty and opportunities to improve patient care. They were further refined to maximize impact and eliminate overlap, and then ranked in order of potential importance both for the specialty and for the public. A literature search was conducted to provide supporting evidence or refute the activities. The list was modified and a second round of selection of the refined list was sent to the workgroup for paring down to the final “top five” list. Finally, the work group chose its top five recommendations before submitting a final draft to the AMDA Executive Committee, which were then approved.

6–10: The AMDA Choosing Wisely® endeavor utilized a similar procedure as published in JAMA Intern Med. 2014;174(4):509-515 – A Top 5 List for Emergency Medicine for our five items.

The AMDA Clinical Practice Committee acted as the Technical Expert Panel (TEP).

Phase 1 – The Clinical Practice Steering Committee (CPSC) along with the Infection Advisory Committee clinicians brainstormed an initial list of low-value clinical decisions that are under control of PA/LTC physicians that were thought to have a potential for cost savings.

Phase 2 – Each member of the CPSC selected five low-value tests considering the perceived contribution to cost (how commonly the item is ordered and the individual expense of the test/treatment/action), benefit of the item (scientific evidence to support use of the item in the literature or in guidelines); and highly actionable (use decided by PA/LTC clinicians only).

Phase 3 – A survey was sent to all AMDA members. Statements were phrased as specific overuse statements by using the word “don’t,” thereby reflecting the action necessary to improve the value of care.

Phase 4 – CPSC members reviewed survey results and chose the five items.

The AMDA Choosing Wisely project utilized procedures similar to previous workgroups.
In Phase 1 – The Clinical Practice Steering Committee (CPSC) solicited recommendations from members of the Society’s five subcommittees.

In Phase 2 – Each member of the CPSC reviewed the submitted recommendations (with the goal to selecting the best five recommendations) considering the
perceived contribution to cost, benefit of the item and scientific evidence to support use of the item in the literature or in guidelines. Based on the feedback of the CPSC, the recommendations were narrowed to five, revised, and supporting evidence was added.

Phase 3 – The revised five recommendations and sources were reviewed by the CPSC for final approval, and then approved by the Board of Directors.

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Tjia, J et al. Daily Medication Use in Nursing Home Residents with Advanced Dementia (2010) JAGS 58 (5) 880-888.

Pelosi, A, McNulty, S. Role of cholinesterase inhibitors in dementia care needs rethinking. BMJ 2006; 333 doi: (Published 31 August 2006)

Deardorff, W.J., Feen, E. & Grossberg, G.T. The Use of Cholinesterase Inhibitors Across All Stages of Alzheimer’s Disease. Drugs Aging 32, 537–547 (2015).

Palmer, J.B., Albrecht, J.S., Park, Y. et al. Use of Drugs with Anticholinergic Properties Among Nursing Home Residents with Dementia: A National Analysis of Medicare Beneficiaries from 2007 to 2008. Drugs Aging 32, 79–86 (2015).

Colloca, G., Tosato, M., Vetrano, D. L., Topinkova, E., Fialova, D., Gindin, J., van der Roest, H. G., Landi, F., Liperoti, R., Bernabei, R., Onder, G., & SHELTER project (2012). Inappropriate drugs in elderly patients with severe cognitive impairment: results from the shelter study. PloS one, 7(10), e46669.

“Deprescribing guidelines.” The University of Sydney, Accessed 6 July 2022.